器质性心脏病室速的导管消融课件

1、器质性心肌病室速的导管消融 在LVEF 25%的患者导管消融可降低ES的风险Europace. 2012;14(12):1734-9.心功能情况在LVEF30%的器质性心脏病患者导管消融可以作为血流动力学稳定单形性室速的首选治疗Maury P, et al. Eur Heart J. 2014 Feb 28.Pts with well-tolerated SMVT, SHD, and LVEF 30% undergoing primary VT ablation without a back-up ICD had a very low rate of arrhythmic death and

2、recurrences were generally non-fatal. Sustained STe-Q and LVEF30% were independent a risk factors of recurrent VT/VF and ES in pts with structural heart diseasesEuropace. 2012;14(5):675-81n = 156心功能情况ICD放电后行室速消融的患者与单纯药物治疗相比有更低的长期死亡率和心衰住院Bunch TJ, et al. Heart Rhythm. 2014 Apr;11(4):533-40.Shock, abl

3、ation n=102No shock, n=2088Shock, No ablationn=817Survival after shock therapy in ICD and CRT-D recipients according to rhythm shocked-The ALTITUDE survival by rhythm study MVT = monomorphic VT; NSVT = nonsustained VT; PMVT = polymorphic VT; SVT = supraventricular tachycardia;Powell BD, et al. J Am

4、Coll Cardiol 2013;62:1674-1679.在ICD患者预防性消融诱发的单形性室速(A) 3D voltage mapping during sinus rhythm shows extending the low-voltage area and the scar in patient with prior inferior MI. (B) Induced VT was haemodynamically intolerated. Paced QRS morphology at site with fragmented potential during sinus rhyth

5、m was similar to the VT QRS morphology. The intracardiac electrogram of the ablation catheter positioned at this area showed mid-diastolic potential during the induced VT. Substrate ablation was performed around this area.Hayashi T, et al. Europace. 2013;15(10):1507-15. Activation Sequence mappingEn

6、trainment mappingPace mappingVoltage Mapping Delayed potential mapping 器质性心脏病室速的导管消融治疗Isthmus identification by mechanisms Substrate Ablation Isolated Diastolic potentialsStable VTPre-systolic potentialIsolated Diastolic potentialEntrainment mapping导管消融治疗瘢痕相关性室速Characterization of Endocardial EP Sub

7、strate in Pts With Nonischemic Cardiomyopathy & MVTHsiaHH, et al. Circulation.2003;108(6):704-10.MVMVMVElectroanatomic substrate for VT in setting of RV CardiomyopathyMarchlinskiFE, et al. Circulation.2004;110(16):2293-8. Peritricuspid Peripulmonic Both valvular Usefulness of thecontactforcesensing

8、catheter to assess the areas of myocardial scar in pts with VTMIZUNO H, et al. J Cardiovasc Electrophysiol. 2013;24:519-524.APAPThe frequency of late potentials in poor contact group was significantly lower com-pared to good contact group (11.9 vs 23.2%; P200 ms, - Shotest RS complex (SRS) 121 ms -

9、V2导联本位转折时间(IDT) 85ms - Maximum deflection index（MDI）最大转折指数， MDI0.55-特发性VT Berruezo A, et al. Circulation. 2004;109:1842 Daniels DV, et al. Circulation. 2006,113:1659在有经验的消融中心，VT经心内膜途径消融失败后，行心外膜标测，而不管VT时QRS波群的形态 Tedrow. J Cardiovasc Electrophysiol. 2009;20:710-713器质性心外膜VT体表ECG特征Berruezo A, et al. Cir

10、culation. 2004;109:1842体表ECG特征 假性波34ms QRS起点至V2最大转折顶点85ms 胸导最短RS120ms机制：心外膜远离Purkinje纤维意义 疤痕范围和部位有一定影响 提示VT出口在心外膜，缓慢传导区未必 意义不如特发性？Endocardial or epicardial VT in NICMRole of 12-lead ECG criteria in clinical practice?IIIIIIaVRaVLaVFV1V2V3V4V5V6Piers SR, et al. Heart Rhythm. 2014 Mar 4. IDT: intrinsic

11、oid deflection time to R wave in V2; MDI: maximum deflection indexPDW: pseudo delta wave;Q-I: Q wave in lead I;SoO: site of origin; SRS: shortest RS complexEndocardial or epicardial VT in NICMRole of 12-lead ECG criteria in clinical practice?Piers SR, et al. Heart Rhythm. 2014 Mar 4. When applied to

12、 25 mm/s ECGs of clinically documented VTs, none of the ECG criteria could differentiate between pts with and those without epicardial VTs. These data suggest that the ECG criteria do not allow identification of pts who are likely to benefit from a primary epicardial ablation approach. 心外膜标测和消融的时机与基

13、础心脏病的关系17名特发性VA中只有2人成功从心外膜消融Epicardial ablation of VT: an institutional experience of safety and efficacy.Tung R, et al. Heart Rhythm. 2013;10(4):490-8. 心外膜标测和消融的时机与基础心脏病的关系Bai R, et al. Circ Arrhythm Electrophysiol. 2011;(4):478-85. Substrate-based Ablation of VAs in ARVD/C心外膜标测和消融的时机心外膜标测和消融的时机Ind

14、ications of Epicardial Ablation and Procedure ApproachesIndications of Epicardial Catheter Ablation Among CentersEpicardial ablation for VT: a European multicenter studyDella Bella P, et al. Circ Arrhythm Electrophysiol. 2011;(5):653-9Dukkipati SR, et al. Circ Arrhythm Electrophysiol. 2011;(2):185-9

15、4. In highly selected pts with HCM, combined epi- and endocardial mapping and ablation is a feasible and reasonably efficacious option for MMVT if refractory to aggressive trials of AADs and antitachycardia pacingLong-term outcomes of combined epi- and endocardial ablation of MMVT related to HCMKOMA

16、TSU Y, et al. J Cardiovasc Electrophysiol. 2013;24:1426-1427,Multimodality Imaging to Improve the Safety and Efficacy of Epicardial Ablation of Scar-Related VTSinus rhythm detection of conducting channels andVTisthmus in ARVCPosterior view of an endocardial bipolar electroanatomic map merged with CT

17、.Fernndez-Armenta J, et al. Heart Rhythm.2014;11(5):747-54.心外膜标测和消融的时机80名非特发性 VT患者消融前行CE-CMR检查，77例成功导管消融患者(96.3%)在CE-CMR上均有局部心肌过度增强(hyper-enhancement, HE)。在VT成功消融部位，3名患者无HE(3.9%)，19名(24.7%)在心内膜，36名为透壁性(46.7%)，8名在中层(10.4%)，心外膜下为11名(14.3%)。VT需行心外膜消融的ICM患者为3例(6.1%)、NICM12例(42.9%)。心外膜下HE预测心外膜起源VT的敏感性为84

18、.6%、特异性为100%。Andreu D, et al. Eur Heart J. 2014;35(20):1316-26Usefulness of contrast-enhanced cardiac magnetic resonance (CE-CMR) in identifying the VT substrate 心外膜标测和消融的时机Andreu D, et al. Eur Heart J. 2014;35(20):1316-26Endocardial HETransmural HEMid-myocardia HEEpicardial HECMR and CARTO map of t

19、wo pts with mid-myocardial HEA/B: Endocardial ablation of PVCs originated from the RV. The distance to theboundary of the HE region was shorter from the RV than from the LV. C/D: Endocardial ablation from the LV. The distance to the boundary of the HE region was shorter from the LV than from the RV.

20、 A previous unsuccessful RF ablation was attempted from the RV. Andreu D, et al. Eur Heart J. 2014;35(20):1316-26Nademanee K, et al. Circulation. 2011;123(12):1270-1279.Prevention of VF in BrS by ablation over the anterior RVOT epicardium 46名VT患者(18 ICM, 13 NICM, 15 ARVC)先行针对Endo-和Epi-LAVA（local abn

21、ormal ventricular activities）的心内膜消融。173次面对Epi-LAVA的心内膜消融中，48 次(28%)成功消除Epi-LAVA (ICM: 20/71 28%, NICM: 3/39 8%, ARVC: 25/63 40%)，伴有Endo-LAVA、心内膜面单极电图幅度低、明显延迟和双极电图幅度低的Epi-LAVA以及Epi-LAVA处在CT扫描上室壁较薄者成功率较高。在4名ICM和2名ARVC患者，心内膜面消融可消除全部Epi-LAVA，而NICM患者均需心外膜消融。在15名ICM(83%)、2名NICM(13%)和11名ARVC患者(73%)中，心内膜消融可

22、部分消除Epi-LAVA。Komatsu Y, and Hassaguerre M, et al. J Am Coll Cardiol. 2014;63(14):1416-2 Endocardial Ablation to Eliminate Epicardial Arrhythmia Substrate in Scar-Related VT心外膜标测和消融的时机Characterization ofcontactforceduring Endocardial and Epicardial ventricular mappingJesel L, et al. Circ Arrhythm Electrophysiol.2014;7(6):1168-73. Inadequate epicardial point with V